anaesthesia
Presented by Dr. Bindu L. Shah
M.D. II yr anaesthesia
Moderator: Prof B.D. Jha
064/11/2
Anatomy
15 -25 grams in weight;; 2 lateral lobes
connected by an isthmus, lie at the level C4-
C7
Closely attached to thyroid cartilage & to
upper end of trachea – thus moves on
swallowing
Close relationship with rec. laryngeal
nerve
Blood flow very high at 5 ml/min/gm (2x
kidney!)
Supply: from superior (1st branch of
External Carotid) and inferior thyroid
arteries ,thyroidea ima artery
Drainage: Sup. mid. and inf. veins
Physiology
Functions of the thyroid gland:
1. Hormone secretions- T3, T4
2. Synthesis of thyroglobulin
Iodine: raw material
Daily requirement: 300-1000 ug/day
Euthyroidism: 150ug/day
For prevention of goitre:75 ug/day
Pregnany: 200ug/day.
Neonatal: 40 ug/day
Biosynthesis and release of thyroid
hormones
1. Iodide uptake:
2. Oxidation: In thyroid, Iodide is converted to
iodine with the help of thyroid perooxidase
3. Iodination of tyrosine residue that are part of
thyroglobulin molecule & formation of
MIT,DIT
4. Coupling / condensation: DIT+DIT=T4,
DIT+MIT=T3
5. Release : endosytosis T3=4ug/day,
T4=80ug/day
Contd.
1/3 of T4 is converted to T3 peripheral
tissue
T3 : 13% (thyroid), 87% (T4)
Nervous system:
1) low-slow mentation; reflexes time
prolomged
2) high-rapid mentation, irritability, restless,
2. Excess- catabolic
a) Beta-blockade:
most rapid method of reversing symptoms
effective within 12 - 24 hrs
may inhibit peripheral conversion of T4 to
T3 as well as blocking beta catech-olamine
receptors
usually only used to tide over while other
therapies take effect
b) Methimazole/Carbimazole
carbimazole is the prodrug of methimazole
iodinated molecule blocks iodination of tyrosine
residues
effects seen after 3 - 4 weeks
can be used as the sole therapy for
hyperthyroidism: given for a period of 12 -18
mths but relapse rate >50%
SFx - rash, arthralgia, N&V
agranulocytosis
c) Propylthiouracil
mechanism of action: a) as for carbimazole and
b) blocks peripheral conversion of T4 to T3
faster onset of action cf carbimazole (due to 'b'
above)
SFx same as carbimazole; can convert from one
drug to the other if SFx a problem
d) Ablative Therapy
Radioactive Iodine (I131)
I131 concentrates in the thyroid and destroys
functioning cells
takes 6 -10 weeks for clinical effect
repeat doses often necessary
hypothyoidism can occur up to years after therapy
aside from hypothyroidism, few side effects
pregnancy an absolute contraindication
no evidence for inherited genetic damage in babies if
mother has had therapy in the past
2. Surgery
Due to I131, surgery for hyperthyroidism is less
commonly required now than in the past.
Subtotal thyroidectomy attempts to preserve the
correct amount of tissue to allow euthyroid state
post-op. Complications include:
hypo- (or occasionally hyper-) thyroidism
hypoparathyroidism
ANAESTHETIC IMPLICATIONS
Hyperthyroidism
Except for absolute emergency surgery, all patients
should be clinically euthyroid prior to surgery.
Pharmacological stabilisation of hyperthyroid patient
requires at least 6 -8 weeks. Beta-blockade combined
with iodide (or lithium) can achieve euthyroid state in 1
-2 weeks but cardiac effects take longer to resolve.
risk of thyroid storm provoked intraop or, more
frequently, postop
other risks of hyperthyroidism:
cardiac failure
increased sensitivity to catecholamine-induced
arrhythmias
Emergency Surgery in hyperthyroid
patient
commence anti-thyroid Rx as soon as
diagnosis made (in conjunction with
specialist endocrinologist)
preop sedation, eg with benzodiazepine
Intraoperatively:
avoid sympathetic stimulation, eg ketamine, pancuronium,
adrenaline in LA
continue beta-blockade titrated to heart rate
consider regional technique to decreased symp. stimulation
monitor HR, Temp, IBP, ETCO2, SpO2, ABGs
may have increased inhalational anaesthetic requirement due to
increased cardiac output, increased temperature, ? CNS
excitation
care with exopthalmic eyes
Postoperatively:
intensive monitoring
Thyroid Surgery
Preoperative Assessment:
1. Gland Function - is the patient clinically euthyroid?
most important indicator of adequacy of medical preparation is
resolution of symptoms, weight gain & normal heart rate
assess cardiac status
history & examination
investigations: CXR, ECG,ischaemia as indicated
review investigations, esp. recent TFTs
keep in mind possible associated conditions; myaesthenia gravis &
rheumatoid arthritis with Graves's disease and phaechromocytoma
with medullary Ca of the thyroid
- Airway:
- Determine ease of intubation
- Compression Symtoms:- hoarseness of voice,
stridor, dysphagia
- Cervical x-ray – tracheal deviation /
compressionr
- Retrosternal spread (SVC obstruction)
Preparation of the patient
Current medication:
continue medication & serve on morning of surgery
Indirect laryngoscopy
- ENT review on vocal cord function as a baseline
finding
Premedication
1. reassurance
A- No difficulty anticipated:
- usual iv induction & intubation (fentanyl, STP, non-depolarizing
muscle relaxant
B- possible difficulty in intubation:
- iv induction, test ventilation when pt is unconscious, intubation
+- suxamethonium
C- definite intubation problem / evidence of airway obstruction
- awake fibreoptic intubation
- inhalational induction
- choice of ETT- armoured ETT (< risk of kinking)
Intraop.
1)Airway obstruction
Possible causes:
- neck haematoma with tracheal
compression
- recurrent laryngeal nerve palsy
- tracheomalacia
- incomplete reversal
Complication, contd.
Symptoms/sign
Onset – intraoperative / 6-24 hours after surgery.
hyperpyrexia,sweating,hyperventilation
CVS: tachycardia atrial fibrillation,CCF,shok
GIT: vomiting, acute abdominal pain
simulation.
CNS: coma, agitation, psychosis, restless,
Precipitants
- Infection
- surgery
- poorly prepared thyroid surgery
- diabetic ketosis
- radioiodine therapy in a poorly prepared pt
- MI
Investigate for precipitants – FBC, blood glucose, FT4,
FT3
Management
vii) Hypotension
viii) Hyponatremia
- caused by dilution & redistribution
- Fluid restriction
ix) Tx of precipitating factors
* Full recovery – replacement thyroxine
dose titrated once / 2-3 weeks to maintain
euthyroid state.
PREOPERATIVE